• Legal procedural delays lead to affected children being institutionalised for prolonged periods, disrupting education and community integration
• Management of pregnancy following rape differs between institutions due to lack of national guidelines

Delays in legal procedures lead to children who have become pregnant as a result of rape and statutory rape being institutionalised for prolonged periods, with prolonged institutionalisation, in turn, causing the disruption of education and making community integration difficult for these victims, while the management of the pregnancy following rape differs between institutions due to the lack of national guidelines.  These observations were made in an opinion article titled “Addressing the mental health needs of adolescents becoming pregnant through statutory rape in Sri Lanka”, which was authored by Y.M. Rohanachandra (Senior Lecturer at the Sri Jayewardenepura University’s Medical Sciences Faculty’s Psychiatry Department and Consultant Child and Adolescent Psychiatrist at the Colombo South Teaching Hospital, Kalubowila) and was published in the of Sri Lanka Journal of Child Health 51(3) in September 2022. Per C. Ekanayake, S. Tennakoon and S. Hemapriya’s “Teenage pregnancies: Obstetric outcomes and their socio-economic determinants – A descriptive study at the Teaching Hospital, Kandy”, the Ministry of Health reports that teenage pregnancies account for 6.5% of the pregnancies in Sri Lanka, while 7.1% of these pregnancies are unwanted. E.S. Muzokura, P. Makoni, and T. Manditsvara’s “Rape-related pregnancy: Concept analysis” defines rape-related pregnancy as a pregnancy occurring as a result of non-consensual sexual intercourse or consensual sexual intercourse with a minor. N. Jayarathna and K.A.A.N. Thilakarathna’s “Jurisprudence of statutory rape” mentions that according to the Sri Lankan law, sexual intercourse with a girl below 16 years of age, with or without her consent, is considered statutory rape. 

1. McIntyre’s “Pregnant adolescents: Delivering on global promises of hope” observes that adolescent girls face health risks in pregnancy and childbirth, which account for 15% of the global disease burden for maternal disorders and 13% of maternal deaths; adolescent females, aged 15-19 years, are more likely to die in childbirth than older females; young females who are 14 years or younger are at the highest risk; and for every young female dying during childbirth, 30-50 others will be left with injury, infection or disease.

Pregnancy itself is a significant stress factor for teenage girls due to negative social attitudes and a huge social stigma. S.C. Hodgkinson, E. Colantuoni, D. Roberts, L. Berg-Cross, and H.M. Belcher’s “Depressive symptoms and birth outcomes among pregnant teenagers”, R.C. Kessler’s “Epidemiology of women and depression”, R.C. Kessler and E.E. Walters’s “Epidemiology of Diagnostic and Statistical Manual of Mental Disorders Third Revision major depression and minor depression among adolescents and young adults in the national co-morbidity survey”, and B.R. Troutman and C.E. Cutrona’s “Non-psychotic postpartum depression among adolescent mothers” note that adolescent mothers experience significantly higher rates of depression before and after the birth of the baby than adult mothers and non-pregnant peers. Per Kessler, around 16-44% of adolescent mothers are estimated to suffer from depression, whereas the lifetime prevalence of major depression in non-pregnant adolescents and adult women ranges from 5-20%. Ekanayake et al. observe that depressive symptoms in young mothers will more likely persist long after the delivery of their child. M. Bayatpour, R.D. Wells, and S. Holford’s “Physical and sexual abuse as predictors of substance use and suicide among pregnant teenagers” and a study among Native Americans found that suicide rates in adolescent mothers range from 11-30%.  The negative psychological consequences of teenage pregnancies are likely to be intensified when the pregnancy occurs as a result of rape. Pregnancy following rape is associated with various adverse psychological consequences such as adjustment disorder, post-traumatic stress disorder, anxiety disorders, depression, increased suicidal risk, substance use disorders, and personality and relationship related issues. Therefore, even though teenage pregnancies resulting from rape account for only a small portion of the pregnancies in Sri Lanka, this population warrants special attention due to the associated negative outcomes. In the Sri Lankan setting, the management of adolescent pregnancy resulting from rape involves the participation of multiple stakeholders, including the obstetric team, the paediatric team, the psychiatric team, judicial medical officers, primary health care workers (public health midwives and medical officers of health), the National Child Protection Authority, the Probation and Social Service Departments, divisional secretariats, the Police, and the legal system. However, there is no national policy or guideline in Sri Lanka to streamline the management approach by each stakeholder within their professional expertise.  This has resulted in different approaches by different parties, in turn making the pregnant teenager further psychologically traumatised even within the system. Several practices used in the management of adolescent pregnancies in Sri Lanka may worsen the psychological trauma in these adolescents. In many instances, adolescents are not given adequate support during labour including pain relief, emotional support and the maintaining of privacy, all of which can add to their emotional trauma.  Many teenage girls who have become pregnant through rape are forced to breastfeed for months while waiting for the baby to be handed over to the Probation Services. In addition, teenagers who have been admitted to residential care for teenage mothers for protection during pregnancy remain in these institutions for a prolonged period due to delays in legal procedures. Such prolonged institutionalisation can lead to the disruption of their education and in turn make it more difficult for them to integrate into society.    Case one   A 13-year-old girl, who had become pregnant following rape, was referred to the Child and Adolescent Mental Health Services (CAMHS) at 36 weeks of pregnancy. She was residing in a care facility for teenage mothers, away from her family. She had an intellectual disability and had a mental age of six years. She had never been to school, could not read or write and had a poor concept of time but was independent in her activities of daily life. She had a poor understanding of sexual intercourse, pregnancy and childbirth.  Her main concern was being separated from her family. Neither she nor her family wished to keep the baby. She had no evidence of a psychiatric disorder. She had a normal childbirth and had been advised to breastfeed by the obstetric ward in keeping with routine practice, to which she had agreed to, albeit reluctantly. In the case conference which was held immediately after the childbirth, a decision was made to handover the newborn to alternative care. Due to the delay in legal procedures, she returned to residential care where she continued breastfeeding reluctantly. She had continuous difficulties with breastfeeding and had been referred for breastfeeding support by the obstetric ward.  She was referred to the consultant paediatrician, who had advised her to stop breastfeeding and had started the baby on formula feeding. A repeat case conference was held and after a two months period of delay, the baby was handed over to alternative care and the child was sent back home.   Case two   A 15-year-old girl was referred to the CAMHS at 35 weeks of pregnancy, following rape. She was residing in a care facility for teenage mothers. She had no contact with her family during her stay at the residential care facility and she worried immensely about being away from her family. She was very anxious and fearful of childbirth and did not want to go through a normal vaginal delivery. She had no evidence of a psychiatric illness.  Neither she nor her family wished to keep the baby. A case conference was held prior to the delivery and delivering the baby through a caesarean section was recommended, in order to minimize the psychological trauma. The separation of the mother and the baby at birth, formula feeding, and the handing over of the baby to alternative care as soon as possible were recommended.  Prior to the delivery, she became highly anxious and was started on a short course of fast-acting, potent tranquilisers of medium duration used to treat anxiety and panic disorders. Due to the legal formalities, following childbirth, she was returned to the residential care facility with the newborn, despite the recommendations.   Case three   A 16-year-old girl with a nine-month-old infant was brought to the CAMHS from a residential care facility for teenage mothers. She had become pregnant following incest and sent to residential care during the pregnancy. She had not wanted to keep the baby at the time of birth and still did not wish to keep her baby.  A decision had been made immediately following childbirth to hand over the baby to alternative care. Due to delays in the legal procedures, she was still in residential care with her baby and was breastfeeding the infant as advised by the staff, however, with great reluctance.  She complained of depressive symptoms since the birth of the baby and had suicidal thoughts with no active plans. She also had thoughts of abandoning the baby and running away. She had minimal eye contact with her baby and avoided the baby’s gaze when breastfeeding. She had a low mood, a lack of interest and loss of appetite. A moderate depressive episode was diagnosed and she was commenced on an antidepressant.  The Department of Probation was contacted and updated about the mother’s mental state and was recommended to speed up the legal process. The mother was sent home two months later after the completion of the legal procedures.   Case four   A 16-year-old girl was brought to the CAMHS with her six-months-old infant. She had become pregnant following rape and was admitted to residential care during the pregnancy. A decision had been made immediately after childbirth to handover the baby to alternative care, as neither she nor her family had wanted to keep the baby at the time.  However, due to the delay in legal procedures, she had been returned to residential care with her baby. For six months, she had breastfed the baby and been the baby’s primary caregiver. By the time the legal procedures were completed, she had developed a strong attachment to her baby and refused to give him up. However, as she lacked the social and financial support to raise her infant and her parents were not willing to support her to raise the baby, the baby was handed over to alternative care as planned. Following this, she developed a moderate depressive episode with suicidal thoughts and had to be started on medication.